Embracing Discomfort: Why Student Physical Therapists Should Be in the Emergency Department
8 minute read
I have learned over the years that the feeling of fear and discomfort before walking into the treatment room never really goes away. I had hoped with years of study, extra training, and certifications that I would no longer have this feeling, but it didn't work. The feeling is still there. Instead, I have learned to lean on my training and use critical thinking to get me through each evaluation, despite the initial discomfort. With experience I have learned to embrace it because it is in that place that I am pushed to become a better physical therapist. If facing my fears makes me a better therapist, how can I teach this to my students? How can they learn to be comfortable with the uncomfortable? It turns out that internships in the emergency department may be one way to do just that.
When I first started in the ED I had a student with me. I wondered how I was going to build the clinical practice with a student following me around. I was fearful because I was representing the field of physical therapy in this novel environment for our medical system. My reputation was on the line. I was also fearful of letting the student see patients because of the complexity and potential risk, but that fear soon subsided. I have been humbled time and time again by what students are able to do by the end of their eight- to 10-week internships in the ED. Not only have the students been able to rise to the challenges, but they have made the physical therapist practice much better. I have learned that the ED is an amazing training ground for instructing students on what it means to become a flexible, independent, critical-thinking PT. More importantly, it gives them the courage to continue into that treatment room despite their fears. Here is a story that highlights exactly that.
The day was over. My student "Alice" and I were about to walk out the door when the ED medical doctor waved us down. Knowing that it was the end of our day, she apologetically asked if we would be willing to consult on a patient for suspected vertigo before she ordered an MRI. We agreed to evaluate the patient knowing that if it was vertigo, we were the right providers at the right time. I smiled and asked my student if she was ready to take on a vertigo evaluation and she agreed without hesitation. Some days we stay late, some days we leave early. It's the nature of ED practice.
We caught a glimpse of the patient from a distance on our way to review the chart. A sense of caution began to grow in me as I took in the details of the scene. The ED was overflowing, and the patient was hooked up to an IV in a busy hallway bed. The patient, an obese minority woman, appeared distressed in the fetal position, holding an emesis bag close to her face. I started picturing the barriers to assessment and treatment. Will the patient be paralyzed by anxiety? Will there be a cultural barrier? Will the patient tolerate a vertigo evaluation? How mobile is the patient? Will we be able to do canalith repositioning maneuvers (Epley) in a hallway stretcher with an IV attached? Where will my student and I sit? I didn't want to stand in the hall next to the bed looking down on the patient the whole time. Ultimately, I thought to myself that my student may just have to observe me on this one.
The chart revealed that the patient had a long history of anxiety, psychological trauma, and drug abuse. There were repeat hospitalizations for psychiatric crisis around this date over the past few years, coinciding with the anniversary of a traumatic event. There were also notes from previous physical therapy consultations that stated the patient prefers to have a female therapist and did not allow a male therapist to fully complete an evaluation. My hands were tied. I did not want to add anxiety to this already distressing situation. Establishing trust and calm was the first priority, and Alice would not be able to do that with me, a male, standing right next to her. Despite being a student, she was the right provider at the right time to see this patient.
Alice and I briefly discussed some of the differential diagnosis to keep in mind during the evaluation: stroke, anxiety, panic, BPPV, neuritis, medications, or a combination of things. Alice had seen symptoms of dizziness and/or vertigo from each of these diagnoses during her ED internship thus far. The patient also had a transient history of inability to ambulate, needing a wheelchair, so we discussed potential mobility barriers. Alice had done several vertigo evaluations in the ED, but she had close supervision and a computer with a premade vestibular evaluation to follow. There was no computer in the hallway. She was going to have to do it from memory. One of the skills that Alice struggled with was explaining across cultural barriers the complexity of vestibular dizziness and why she was going to make them feel worse to get better during the testing and treatment. There's only one way to get better. Practice.
Given that the patient was in a hallway, I could observe from a safe distance. Alice grabbed a chair and sat down in the middle of the hall forcing the traffic to go around, creating a safe space to converse. The patient described classic symptoms of BPPV: dizziness/spinning sensation with looking to the left, sitting up, and laying down. Dizziness only lasts 10-20 seconds or so. The patient then opened up about other symptoms of chronic pain flaring up and her struggle with grief due to the past trauma. Alice was excited, the patient literally paved the way for her to give some neuroscience education on how a ramped-up nervous system in the setting of acute anxiety and past trauma can elevate symptoms of pain and even vertigo to the point that it is an emergency. Alice was about to say something, but stopped. She acknowledged the patient's subjective reports with empathy and decided to conduct a thorough physical evaluation before providing education.
The patient tested positive for left BPPV. Neurologic, cardiac, neuritis/labyrinthitis, cervical dizziness, migraine, and medication screens were all negative. The patient was treated with Epley maneuver twice, right there in the hallway with near full resolution of symptoms. Alice had the patient walk around the ED and complete a dynamic balance test. The patient passed the test and was able to ambulate safely without an assistive device. After, Alice sat down with the patient at the edge of the bed. She was able to provide encouragement and then safely provide some neuroscience education. The patient reported feeling much better and verbalized a better understanding of both her acute and chronic situations. Finally, Alice was able to convey her findings and recommendations to the doctor. No MRI was ordered, and the patient was safely discharged to home.
I was speechless. I was proud of my student for taking on this complex, challenging situation, and even more so the restraint. Alice was given the perfect opportunity to chase the patient's anxiety and start educating her, but she didn't. She showed restraint. She ruled out red flags and developed a treatable physical therapy diagnosis with a proper exam first. A common mistake that students (and PTs) make, is providing neuroscience education based on assumptions made from the subjective without a proper evaluation. Alice trusted her training and acknowledged, but was not swayed by, the patient's anxiety. Ultimately, Alice helped the patient feel better earning the patient's trust with a thorough evaluation, therefore earning the right to provide some advice about the anxiety, grief, and its interaction with the nervous system. Furthermore, had Alice declined to take this evaluation, the patient would have likely gotten an unnecessary MRI. She would have been stationed in the hallway for hours, late into the night. The patient's symptoms of vertigo and anxiety would have been medicated, but not treated. Based on my experience there would have been a high probability of admission to the hospital.
This is an example of what a student is capable of doing with the right training and exposure. The ED is the perfect experiential learning site for students to see complex situations every day and practice their evaluation skills. It forces flexibility, critical thinking, and communication across multiple disciplines. The ED challenges a student physical therapist to practice nearly everything that they have learned in school about evaluation, differential diagnosis, and communication at the level of consultant for the medical team. When my students leave their ED internship, they unanimously report that the experience was enormously challenging, yet at the same time confidence building. They thank me for preparing them to take on difficult and complex patients once they start practicing on their own. They thank me for learning to face their fears and embrace the discomfort.
I also write this as a challenge to myself and the physical therapy community, a challenge to take students right into the thick of it with you — into those situations we fear that our reputations could be on the line. Give them a chance to fail safely. Trust that the practice we worked hard to build will likely succeed despite us, and it will be our students who replace us. Who knows, in the meantime they might make us better therapists too.
Acknowledgements: A special thanks to the student physical therapists who have been in the ED with me, as we navigated these somewhat uncharted waters.
John Seip, PT, DPT, is a physical therapist working full time in an emergency department as part of an acute care team in a level one trauma hospital in Duluth, MN. You can connect with John on Twitter, LinkedIn, or by email.